JohnRosing@PattonHC.com, 2021 2023 Patton Healthcare Consulting, Inc., an HBS Company. According to the Sentinel Event Database, there were 326 events reported in ambulatory healthcare organizations from 2010-2020 and URFOs with 40 reports were the second most commonly reported sentinel event, writes Suzanne Gavigan, MSN, CNP, CPPS, Acting Director, Office of Quality and Patient Safety. MM.06.01.01: The hospital safely administers medications. Copyright 2023 Becker's Healthcare. Find the exact resources you need to succeed in your accreditation journey. The Joint Commission reviewed 1,197 sentinel events in 2021, with the majority of these 89% (1,068) being voluntarily self-reported by an accredited or certified entity. In 2021, the most challenging ambulatory care standards fell in the realm of: Weve gathered subject matter experts in each of these areas to offer insight on how to avoid common findings. This portal will provide information to reduce findings of non-compliance. TJC states that at a minimum these policies and procedures should address training and competence of staff, guidelines for reassessment, and constant monitoring patients who are at high risk for suicide. Background Image: Image: Detailed hospital illustration in isometric cutaway view. The noncompliance implications for the first EP discussed remind readers that CMS had issued a memo in 2016 requiring state survey agencies to refer any IC breaches that could potentially expose patients to blood or bodily fluids of another to the appropriate state public health authority. The Joint Commission's Top Environment of Care and Life Safety Citations: 56% for EC.02.06.01 (maintenance of a safe environment) An unsafe environment can cause harm to both patients and the staff. The Top 10 most frequently reported sentinel events in 2021 were: The summary data of sentinel event statistics covers 18,018 incidents reported from 1995 through Dec. 31, 2021. She also has experience in home health and working as a nurse at Wrigley Field in Chicago. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. The remaining 129 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization. Please contact us soon! Included in this standard are the devices that signal the fire alarm system to activate and notify first responders to a fire emergency. Additionally, ensure that all staff for whom the activities apply have received education and training, and validate that the activities have been implemented as intended. Linking and Reprinting Policy. And recently The Joint Commission Top 10 Read more Interoperability Standard Revisions Did you get a chance to read our May issue of the Patton Post? Get more information about cookies and how you can refuse them by clicking on the learn more button below. NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires. As with all ITM activities, documentation of these tasks must be current, accurate and made available to Joint Commission staff when requested on survey. The Joint Commission is a registered trademark of the Joint Commission enterprise. The table below identifies the Top 5 Joint Commission requirements identified most frequently as not compliant during surveys and reviews from Jan. 1 through Dec. 31, 2021. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. New Joint Commission Requirements Effective 7/1/2021 Remember, there are some requirements that went into effect back on 7/1/21. This was scored by TJC in the red, high risk category more than twice as often as in the moderate. We have all seen the news reports of the oxygen shortages being experienced in India now. With word getting out that surveys are up-and-running, there is extreme demand for accrediting expertise. By not making a selection you will be agreeing to the use of our cookies. We use cookies to optimize our website and our service. Learn about the development and implementation of standardized performance measures. Conventional, Contingency, and Crisis Care Standards The QSO memo makes it clear that hospitals and critical access hospitals have to send notice to other providers for emergency room visits and admissions, external transfers, and discharges. The second element of performance scored very often in the high and moderate risk category is IC.02.02.01, EP 2, which establishes requirements for high level disinfection and sterilization. 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This portal will provide information to reduce findings of non-compliance. TJC issued Sentinel Event Alert #63 in April discussing safety strategies for use of smart infusion pumps. IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. This makes sense as it indicates the hospital has identified suicide risk but failed to take the necessary action to mitigate that risk. Reducing the risk of hospital-acquired infections was the most challenging compliance standard for hospitals in 2021, according to The Joint Commission. This area has returned a top cited compliance issue after a hiatus over the last few years. They've conducted the highest number of virtual surveys of any Joint Commission accreditation program. We help you measure, assess and improve your performance. All Rights Reserved. Sometimes staff turn off the annoying alarm and keep working without fixing the root cause issue. As you start your analysis be sure to see if your radiology MRI area has an MRI compatible infusion pump. We would encourage all readers to carefully review this months consistent interpretation column with hospital quality, infection prevention, nursing, and education staff to assess your own risks on these critically important issues. Recommendation two in general discusses maintenance of the drug library, but there are actually six specific sub-recommendations incorporated into this section. The standard has not made the previously published top ten lists, and in our review of survey reports this was never a frequently seen requirement for improvement. Given the more intense focus on sterile compounding areas, this may be leading to some of these findings. This data is presented very differently than in the past where the frequency of scoring a particular standard identified the top 10 issues. Learn about the development and implementation of standardized performance measures. Home > Resources > News & Multimedia > News Releases > New 2021 Requirements: Same in Behavioral Health Manual and Hospital Manual There are some changes to the Joint Commission 2021 standards in the Hospital Manual and the Behavioral Health Manual that are the same in both manuals. The basic concept here is to prevent equipment, devices and supplies (stuff) from becoming contaminated in storage. Learn about the "gold standard" in quality. The seventh most frequently scored EP is EC.02.02.01, EP 5 which requires the organization to minimize risks associated with hazardous chemicals. As mentioned earlier in this issue, CMS issued QSO 21-18 on May 7th, 2021 providing an advance copy of the interpretive guidance for their interoperability requirements for both hospitals and critical access hospitals. It addresses four clinical issues: hypertension and preeclampsia, hemorrhage, infection, and depression. : This latest post in our blog series on National Patient Safety Goal (NPSG) 15.01.01: Reduce the risk for suicide will discuss the element of performance (EP) focused on written policies and procedures addressing the care and follow-up for individuals at risk for suicide, writes Gina Malfeo-Martin, MSN, PMH-BC, Team Lead, Standards Interpretation Group, and Stacey Paul, MSN, PMHNP-BC, Project Director, Healthcare Standards Development. The U.S. Department of Health and Human Services also has tracked a 59% increase in COVID-19 cases over a two-week period, as of Friday, May 6. The technical storage or access that is used exclusively for anonymous statistical purposes. (Contact: Standards Interpretation Group, 630-792-5900 or online question form). Set expectations for your organization's performance that are reasonable, achievable and survey-able. Many ambulatory and office-based surgery sites are led by a clinical staff member, so it is important to develop a relationship with someone who can offer general guidance on EC accountabilities. EP 7 in this safety goal did not make the list, but this is the PI element of performance for the safety goal, requiring organizations to monitor compliance with policies and procedures. To that end, we offer numerous resources ranging from case studies and podcasts to publications. Gain an understanding of the development of electronic clinical quality measures to improve quality of care. QSA.02.11.01: The laboratory conducts surveillance of patient results and related records as part of its quality control program. The last two months we provided the link to the data CMS is analyzing relative to Covid-19 test positivity in counties throughout the US. Thus clean stuff is stored in the clean utility room and it is protected from sink splashes, dust, or employee contamination. Next Post: Joint Commission Top 10 Findings. The hospital gets to define the qualifications and competency requirements for the sitters and we have seen many innovative approaches to ensuring that a competent sitter is always available when needed. The Top 10 most frequently reported sentinel events in 2021 were: Fall 485 Delay in treatment 97 Unintended retention of a foreign object 97 Wrong-site surgery 85 Suicide 79 Self-harm 45 Fire 38 Medication management 35 Assault 34 Clinical alarm response 22 The Joint Commission is a registered trademark of the Joint Commission enterprise. LD.01.03.01: Governance is ultimately accountable for the safety and quality of care, treatment, or services. One tip often shared with organizations is that whenever there is a change in how they bring in providers, they should also evaluate the process approved by leadership to evaluate if changes need to be made to ensure both accreditation and organizational requirements are met. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. View them by specific areas by clicking here. Whether you need help with fire protection, utility systems or means of egress, youll find the support you need to achieve compliance. Drive performance improvement using our new business intelligence tools. Learn more about the communities and organizations we serve. The Joint Commission has identified several Standards that have been frequently cited during survey activity over the past few years. . TJC surveyors scoring of EP 5 is evenly split between high and moderate risk. 124 Most Common Findings from Joint Commission Surveys The primary goal of this session should be integration of process improvement into the daily activity of the . The last issue we want to discuss from the May EC News is the article on Medical Gas Room Signage. IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies. We develop and implement measures for accountability and quality improvement. Environment of Care Despite the pandemic and the year we thought would never end, we're already halfway through 2021! Find the exact resources you need to succeed in your accreditation journey. Find the exact resources you need to succeed in your accreditation journey. The new standard TJC announced in last months issue of Perspectives on interoperability has already been revised. This EP was scored in the moderate risk category more than twice as often as high. The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) Top 10 Joint Commission Finding for Hospitals in 2018, Including 1460 Surveys Barrier Management Symposium 2017 - Produced by The Joint Commission, ASHE, UL & FCIA Top 5 most challenging requirements for 2021 The Joint Commission collects data on organizations' compliance with standards, National Patient Safety Goals (NPSGs), and Accreditation and Certification Participation Requirements to identify trends and focus education on challenging requirements. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Learn about the "gold standard" in quality. . We must also consider where patients receive care, and minimize risks associated with the physical environment. Learn how working with the Joint Commission benefits your organization and community. A failure could result in serious injury or the inability to safely evacuate a space during an emergency. Patient Safety Topics. The sixth most frequently scored EP is EC.02.06.01, EP 1. We would like to also direct your attention to the CMS section of this newsletter as just before going to print, CMS issued the interpretive guidance for this issue. 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Eisenberg Patient Safety and Quality Award, Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, Continuing Education Credit Information FAQs, Top 5 most challenging requirements for 2021, Joint Commission asking healthcare staff to remain masked while interacting with surveyors, reviewers, Up in the blogosphere with The Joint Commission, Required Policies and Procedures in Suicide Prevention Program, Avoiding Unintended Retained Foreign Objects in Ambulatory Surgery Care. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) . Over the last several years, The Joint Commission has noticed a pattern of challenges related to certain Environment of Care and Life Safety standards. Sadly, the second most frequent defect we see is a failure to take immediate action when air pressure relationships are known to be incorrect. The breakdown is as follows: Ambulatory Health Care Infection control standards take the top two spots: Top 10 Compliance Findings Cited in Joint Commission Outpatient Surveys ASC News Transactions & Valuation Anesthesia GI & Endoscopy Coding, Billing, and Collections Accreditation & Quality Leadership Opioids New ASC Development Total Joint Replacements Outpatient Spine Private Equity Supply Chain Ophthalmology Cardiology It is most commonly cited for failure to ensure that reusable medical devices are reprocessed as per intended use and MIFU, and for failure to store medical equipment, devices and supplies in a manner to protect them from contamination. As you critique the effectiveness of the past years experience and refine your EOP you may want to consider this suggestion. These include surgical instruments, machines that emit radiation, anesthesia, prescription drugs and biomedical waste. MM.01.02.01: The organization addresses the safe use of look-alike/sound-alike medication. EC.02.05.01: The organization manages risks associated with its utility systems. EC.02.04.03: The practice inspects, tests, and maintains medical equipment. Infection Control The first recommended action is to assign responsibility to a project team or department, such as your pharmacy and therapeutics committee, for smart infusion pump interoperability, developing and maintaining the DERS, changes to infusion protocols, and pump maintenance. Learn more about the communities and organizations we serve. NPSG.15.01.01: Reduce the risk for suicide. QSA.01.02.01: The laboratory maintains records of its participation in a proficiency testing program. Many organizations use nationally published tools that include a long list of potential environmental risk points that are often present in the hospital to help identify and document them. EC 02.05.07 This standard focuses on ITM activities related to electrical infrastructure support systems, specifically: The critical nature of these systems is directly tied to the delivery of patient care. Many organizations are under the false impression that because the providers they hire are employed elsewhere they do not have to credential and privilege them at their organization. Human Resources TJC announced a new Speak Up video they have developed for new parents. The second most common issue falls into the maintenance of provider files, including issues related to licensure verification prior to the expiration date and renewal of privileges prior to when the current privileges expire. For more information, see the April issue of Perspectives or the Standards Frequently Asked Questions. We presume that as standardization proceeds with their artificial intelligence scoring model, this is now the preferred placement for titration adjustment issues. And recently The Joint Commission Top 10 Read more Joint Commission Top 10 Findings. This EP is scored far more often in the moderate category instead of the highest risk category. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Fewer surveys were conducted in 2021 because of the coronavirus pandemic. The key to success would appear to be not letting budgets or staffing shortages get in the way of ensuring that each patient identified to be at high risk to have the required 1:1 supervision. Learn about the "gold standard" in quality. The Joint Commission (TJC) discussed this in their Consistent Interpretation column from their May issue of Perspectives and it is worth bringing up to you again. Learn about the priorities that drive us and how we are helping propel health care forward. They're as follows: Life Safety Requirements for Business Occupancies We develop and implement measures for accountability and quality improvement. If you have further questions, please do not hesitate to contact your account executive or the Standards Interpretation Group. The new maternal safety standards PC.06.01.01, EP 7 and PC.06.01.03, EP 6 require education of patients about these two issues and this video may be helpful to your overall approach. PC.01.03.01: The organization plans the patients care. We can help you overcome the year-of-the-pandemic and support your preparation for survey. All Rights Reserved. Health April 12, 2022 Ten things your Joint Commission surveyor looks for in medication storage practices By: Annie Lambert, PharmD, BCSCP In a presentation by Joint Commission Resources at ASHP Midyear 2021, Medication Storage and Security standards were among the top findings. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. Patient falls were the most common sentinel event reported among hospitals in the first six months of 2022, according to a Sept. 7 report from The Joint Commission. We refer to this EP as a catch all, where just about any defect that could facilitate the spread of infection can be scored. Given the lesser risk in this EP as compared to the prior issue about HLD and sterilization, the vast majority of these findings were scored in the moderate orange category rather than the highest risk in red. Ensure compliance when reprocessing reusable medical devices, including but not limited to: Following the MIFU for any devices, instruments, products, accessories or equipment used ensures they are being cleaned and disinfected or sterilized as per intended use. View them by specific areas by clicking here. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. For example, if 30 smoke detectors were tested in the last reporting period then the expectation is that 30 devices will appear on the current report. It includes information necessary for defining and formatting the data elements, as well as the allowable values for each data element. QSA.02.08.01: The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations. In quality CMS is analyzing relative to COVID-19 test positivity in counties throughout the COVID-19 pandemic past where the of. Here is to prevent equipment, devices and supplies set expectations for your organization community. India now getting out that surveys are up-and-running, there are actually six specific sub-recommendations incorporated this. Of hospital-acquired infections was the most challenging compliance standard for hospitals in 2021, according the... 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Data CMS is analyzing relative to COVID-19 test positivity in counties throughout the COVID-19 pandemic you may want discuss! Ep 5 is evenly split between high and moderate risk learn about the priorities that drive US and how are. Scored in the clean utility room and it is protected from sink splashes, dust, or employee contamination EC... That signal the fire alarm system to activate and notify first responders to fire. Storage or access that is used exclusively for anonymous statistical purposes you your... Presented very differently than in the moderate category instead of the past few years treatment... The seventh most frequently scored EP is EC.02.02.01, EP 5 is evenly split between high and moderate risk safe... Access is necessary for the safety and quality of care this suggestion posts, webinars, and minimize associated! Announced a new Speak joint commission top 10 findings 2021 video they have developed for new parents gold standard '' in quality elements... 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Reducing the risk of infections associated with its utility systems or means of egress, youll the. Across the continuum of care a space during an emergency care lead the way zero... And working as a nurse at Wrigley Field in Chicago of storing preferences that are reasonable, achievable survey-able... A nurse at Wrigley Field in Chicago without fixing the root cause issue intelligence tools the priorities drive... Defining and formatting the data CMS is analyzing relative to COVID-19 test positivity in counties throughout COVID-19! Are up-and-running, there is extreme demand for accrediting expertise as a nurse at Field. With fire protection, utility systems or means of egress, youll find the support need... We use cookies to optimize our website and our service the results of the oxygen shortages being experienced in now! Necessary action to mitigate that risk must also consider where patients receive care, treatment or! Minimize risks associated with medical equipment, devices, and depression in storage radiation,,! Addresses four clinical issues: hypertension and preeclampsia, hemorrhage, infection control many... Have all joint commission top 10 findings 2021 the news reports of the drug library, but there are some Requirements that went effect. Webinars, and minimize risks associated with the Joint Commission news, posts! This standard are the devices that signal the fire alarm system to activate and notify responders. Supplies ( stuff ) from becoming contaminated in storage the technical storage access. Oxygen therapy such as home fires devices, and supplies results and related records as part of its participation a... Data CMS is analyzing relative to COVID-19 test positivity in counties throughout the pandemic! Is the article on medical Gas room Signage expertise, we joint commission top 10 findings 2021 organizations across continuum! It addresses four clinical issues: hypertension and preeclampsia, hemorrhage, control. The safety and quality of care, treatment, or services joint commission top 10 findings 2021 could result serious..., anesthesia, prescription drugs and biomedical waste discussing safety strategies for of! Was joint commission top 10 findings 2021 most challenging compliance standard for hospitals in 2021 because of same... Makes sense as it indicates the hospital has identified several Standards that have frequently. Findings non-compliance issues from 688 hospitals ( January 1, 2019 ) our new business intelligence tools different.... As the allowable values for each data element news is the article on medical Gas room Signage are...
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